Workers Compensation
And Employers Liability
Insurance Policy
- Information Page

WC 00 00 01 A

Original Printing                                          Issued May 1, 1988                                    Standard

INFORMATION PAGE

Insurer

POLICY NO.

 

1.     The Insured:

_____Individual

____Partnership

     Mailing address:

Corporation or_____________

     Other workplaces not shown above:

 

 

2.     The policy period is from __________ to __________ at the insured's mailing address.

3.     A.     Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here:

B.     Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are:

 

Bodily Injury by Accident $_________ each accident
Bodily Injury by Disease $__________ policy limit
Bodily Injury by Disease $__________ each employee

 

C.     Other States Insurance: Part Three of the policy applies to the states, if any, listed here

D.     This policy includes these endorsements and schedules:

4.     The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit.

 

Classifications

Code No.

Premium Basis Total EstimatedAnnual Remuneration

   Rate Per $100 of Remuneration

Estimated Annual                                              Premium

 

Total Estimated Annual Premium $

 

Minimum Premium $

Expense Constant $

Countersigned by________________________________

 

 

 

© 1987 National Council on Compensation Insurance